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The Clearing House on Male Circumcision, in collaboration with the United States Agency for International Development, the U.S. Centers for Disease Control and Prevention, the Office of the U.S. Global AIDS Coordinator, the Joint United Nations Programme on HIV/AIDS, and the World Health Organization, have released policy papers on potential costing and impact of male circumcision in 14 countries in East and Southern Africa. These policy papers support efforts to scale up male circumcision in the U.S. President’s Emergency Plan for AIDS Relief programs and are intended to promote the use of the Male Circumcision: Decision Makers’ Program Planning Tool (2009, PDF, 1.71 MB) with more detailed in-country data. Readily available data have been applied to estimate the potential cost and impact of scaling-up medical male circumcision services. The results presented in each of these policy briefs illustrate one of several possible scenarios and can be modified to reflect a range of different policies at the country level.

On World AIDS Day, December 1, 2009, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) issued the Five-Year Strategy. This strategy outlines the high-level direction of the program during the next five-year phase. It reflects lessons learned in the first five years of the program, expands existing commitments around service delivery, and places a heightened emphasis on sustainability. According to the plan, during the next phase PEPFAR will:

• Transition from an emergency response to promotion of sustainable country programs. • Strengthen partner government capacity to lead the response to this epidemic and other health demands.• Expand prevention, care, and treatment in both concentrated and generalized epidemics.• Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. • Invest in innovation and operations research to evaluate impact, improve service delivery, and maximize outcomes.

In addition to these overarching goals, PEPFAR’s Five-Year Strategy announces new targets for the program for prevention, care and support, treatment, and sustainability. Annexes to the PEPFAR Strategy are also on the website and provide additional information about specific program areas.

Globally, HIV and other sexually transmitted infections account for 6.3 percent of the burden of disease, and alcohol for 4 percent. Much of sub-Saharan Africa, in particular, carries a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. According to the authors of this study, implementation of known effective multi-level structural interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, sexual violence, unintended pregnancy, and HIV transmission. Physiological and behavioral research indicates that alcohol independently affects decision-making concerning sex, skills for negotiating condoms and their correct use, and risk of sexual violence. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking, a finding strongly consistent across studies and similar between women and men. Brief interventions for people with problem drinking must incorporate specific discussion of links between alcohol and unsafe sex, and the consequences thereof. Interventions to reduce alcohol harm among HIV-infected people are also an important element in positive-prevention initiatives. Control of alcohol use, including alcohol-sex linkages, has been prioritized by the World Health Assembly, and although implementing these measures will take political courage, there could be notable long-range effects.

Informal, interpersonal communication within a community about HIV and AIDS, or lack of such communication, may influence community members’ uptake of voluntary counseling and testing and other health behaviors, according to this cross-sectional study in Africa. Drawing from Noelle-Neumann’s spiral of silence theory, the authors examined the association between communication about HIV/AIDS and prior HIV testing in 48 communities across five sites in Tanzania, Zimbabwe, South Africa, and Thailand, with 14, 818 participants completing a behavioral baseline survey assessing communication, prior voluntary counseling and testing (VCT) uptake, social norms, stigma, and sexual risk. The only variable that was significantly and consistently associated with past HIV testing at every site was common conversations about HIV. Odds ratios for each site ranged from 1.885 to 3.085, indicating a roughly doubled or tripled chance of past VCT uptake. Results indicate that verbal communication may be an important mechanism for increasing health behaviors, and inclusion in future interventions should be considered. The authors indicate that to increase future VCT uptake in groups where testing uptake is low, interventions must focus on increasing conversations among men and encouraging repeat testing. Such actions may enable more individuals to know their current HIV status and thereby make informed choices about risk and care.

Current family planning (FP) practices in Uganda, a country with one of the highest fertility rates (TFR) worldwide, contribute as much or more to mitigating pediatric HIV than antiretroviral prophylaxis (ARV) and prevention of mother-to-child transmission (PMTCT), argue the authors of this study. Using a baseline mathematical projection to estimate the current pediatric HIV burden in Uganda, they compared the effects of ARV for PMTCT to that of FP, finding that every day in Uganda, FP averts approximately 20 vertical infections and 9 pediatric AIDS deaths. This comparative analysis suggests that existing FP services significantly contribute to the goals of PMTCT, exceeding the current achievements of ARV-PMTCT alone. At the same time, unwanted fertility in Uganda accounts for a substantial amount of pediatric HIV disease and will continue to do so unless access to FP services improves significantly. Modern FP methods are safe, cost-effective, and provide substantial benefits for PMTCT and beyond. Targeting FP services for HIV-infected women could have a dramatic positive effect for PMTCT. According to the authors, donors, policymakers, and program planners need to acknowledge and embrace the real contribution of FP for PMTCT and support its expansion.

Men who have sex with men (MSM) are at high risk for HIV infection in many low-income and middle-income countries (LMIC), and yet in these same countries HIV prevention responses for MSM do not reach satisfactory numbers of MSM and need substantial strengthening. This study presents global estimates on key HIV prevention needs and responses among MSM in LMIC. Data on HIV testing, HIV prevention coverage, HIV knowledge, and condom use among MSM were derived from United Nations General Assembly Special Session country progress reports submitted in 2008. Eligible country estimates were used to calculate global and regional estimates, weighted for the size of MSM populations. Of 147 LMIC, 45 percent reported at least one indicator that reflects the HIV prevention needs and responses in MSM. Global weighted estimates indicate that on average 31 percent of MSM in LMIC were tested for HIV; 33 percent were reached by HIV prevention programs; 44 percent had correct HIV knowledge; and 54 percent used condoms the last time they had anal sex with a man.

Following this analysis, the authors conclude that extending and improving monitoring, research, and prevention among MSM in LMIC is not only a matter of promoting sound public health practices, but also contributes to protecting their human rights.

Progress has been made toward eliminating blood transfusion as a significant cause of HIV infection globally. Screening all donated blood for HIV in accordance with minimum quality standards remains vital, however, as health care systems should, at a minimum, do no harm. This study examined two global databases for blood safety: 1) the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) blood safety indicator, collected through the Ministry of Health in each country and cross checked by the World Health Organization and United Nations Programme on AIDS (UNAIDS); and 2) the Global Database on Blood Safety (GDBS), a database developed by the World Health Organization. Altogether, 125 United Nations Member States (85 percent of the 147 that participated in UNGASS) submitted data on blood safety. Ninety-one of the 125 countries (73 percent) reported that 100 percent of collected blood units were screened in a quality-assured manner, but 34 countries did not screen all collected blood units in accordance with minimum quality standards. GDBS data showed that 80.7 million blood units were collected globally in 167 countries during 2004–2005, of which 77.3 million were tested for HIV, and at least 0.6 million of the remaining 3.4 million donations went untested.

Despite several years of implementation, prevention of mother-to-child transmission (PMTCT) programs in many resource-poor settings fail to reach the majority of HIV- positive women, concludes this data-driven study from a high HIV-prevalence district in South Africa. An initial participatory quality improvement intervention was implemented, consisting of an assessment; workshops to assess results, identify weaknesses, and set improvement targets; and continuous monitoring to support changes. The assessment also identified weaknesses in training and supervision, and poor coverage of all program indicators except HIV testing. To address these shortfalls, monthly support to all facilities took place, including an orientation to the PMTCT protocol, review of local data, and identification of bottlenecks to optimal coverage using a continuous quality improvement approach. One year following the intervention, large improvements in program indicators were observed. Coverage of CD4 testing increased from 40 to 97 percent, uptake of maternal nevirapine from 57 to 96 percent, uptake of infant nevirapine from 15 to 68 percent, and six-week PCR testing from 24 to 68 percent. This relatively simple participatory assessment and intervention process has enabled program managers to use a data-driven approach to improve program coverage.

Summarizing the available data on the association of circumcision status and HIV/STI acquisition among men who have sex with men (MSM), the authors of this review find that circumcision has limited impact among MSM populations overall. Recent studies, however, have found that circumcised MSM who predominantly take the insertive role in anal intercourse may be at a lower risk of HIV infection, although the relative inefficiency of HIV acquisition for insertive compared with receptive partners has resulted in imprecise estimates of effect. Longitudinal data also suggest that circumcision may reduce the risk of incident syphilis, but there is little evidence of a protective effect for other STIs. A recent mathematical transmission model estimated that circumcision of adult MSM may be cost-effective in resource-rich settings, even those with baseline moderate-to-high male circumcision prevalence. The authors add that although MSM may be willing to undergo adult circumcision, should it be proven to reduce HIV acquisition risk, there is substantial potential that behavioral disinhibition could offset any benefits achieved by a circumcision intervention.

Mathematical models can estimate the population-level impact of male circumcision on HIV incidence in high HIV- prevalence settings, but different methods, assumptions, and input variables can produce conflicting results, according to experts from UNAIDS, WHO, and the South African Centre for Epidemiological Modelling. The authors report large benefits of male circumcision among heterosexual men in low male-circumcision, high HIV- prevalence settings, with one HIV infection being averted for every 5 to 15 male circumcisions performed, and costs to avert one HIV infection ranging from US$150 to US$900 using a 10-year time horizon. The models predicted that both premature postoperative resumption of sexual intercourse and behavioral risk compensation, if confined to newly or already circumcised men and their partners, have only small population level effects on the anticipated impact of male circumcision service scale-up on HIV incidence. Women benefit indirectly from reduced HIV prevalence in circumcised male partners, and male circumcision service scale-up acts synergistically with other strategies to reduce HIV disease burden. The modeling results have informed development of a pragmatic decision makers’ program planning tool.

Although many microbicide candidates for HIV prevention have been discarded due to safety issues or lack of efficacy, lessons learned over the last two decades provide hope that a safe and effective one can be developed, explains the author of this review. With the approximately 50 candidate microbicides currently in development (see www.microbicide.org, for a full list), there has been a move from broad-spectrum microbicide products to antiretroviral microbicides that target specific steps in the viral life cycle. Phase 2B/3 effectiveness studies of surfactant and polyanion vaginal microbicides have demonstrated modest or no effect against HIV infection, and in the case of nonoxynol-9 and cellulose sulfate, the potential to increase the risk of HIV acquisition. However, newer antiretroviral microbicide candidates such as tenofovir have shown good safety and significant efficacy in animal models and human tissue explant systems, and are currently being evaluated in human effectiveness studies. New formulation platforms such as vaginal rings are being developed to optimize product acceptability and adherence, and far greater scrutiny of candidate microbicides is happening at both the preclinical and early clinical phase of development.

Stigma is a complex social construct that must be monitored over time, according to this report, which provides the first quantitative evaluation in Africa of the changing nature of stigma and the potential determinants of these changes. Data collected in Cape Town in 2003 and 2006 for 1,074 young adults aged 14-22 years were used to evaluate changes in three distinct dimensions of stigma: behavioral intentions towards people living with HIV/AIDS; instrumental stigma; and symbolic stigma. Results indicate that each dimension of stigma increased in the population as a whole, and for all racial and gender sub-groups. Symbolic stigma increased the most, followed by instrumental stigma, while negative behavioral intentions showed a modest increase. Knowing someone who died of AIDS was significantly associated with an increase in instrumental stigma and symbolic stigma, while increased personal contact with people living with HIV/AIDS was not significantly associated with any changes in stigma. Despite interventions, such as public-sector provision of antiretroviral treatment, stigma increased among a sample highly targeted with HIV-prevention messages. The authors conclude that renewed efforts are necessary to reduce stigma, perhaps through interventions to weaken the association between HIV/AIDS and death, to reduce fear of HIV/AIDS, and to recast HIV as a chronic, manageable disease.

Since 2001, a large majority of countries have integrated issues relating to women into their national HIV policies and strategic plans, reported data disaggregated by sex and age, and attained gender equity in HIV testing and the delivery of antiretrovirals. Countries and regions with low-level or concentrated HIV epidemics, however, lag behind countries with generalized epidemics in integrating women-focused policies into national frameworks, and lack engagement of development ministries in women’s social and economic empowerment. This article examines a report back of United Nations General Assembly Special Session on HIV/AIDS (UNGASS) data on policies and strategies affecting equity for women and men. A total of 82 percent (108 of 130) of countries report having policies in place to ensure that women have equal access to HIV-related services, but 14 percent of reporting countries also have laws and policies that hinder their ability to deliver effective HIV programs for women. About 80 percent of countries report having included women as a specific sector in their multisectoral AIDS strategies or action frameworks; however, only slightly more than half (53 percent) of those countries report having a budget attached to programs addressing women’s issues. By the end of 2007, women represented a slight majority of the 33 percent of those receiving treatment.

To make a dent in the HIV epidemics among people who inject drugs (PWID), national AIDS programs should urgently scale-up opioid substitution therapy and needle-syringe program services to cover at least 50 to 60 percent of PWID and make these programs widely available both in community and closed settings. This article examines the magnitude of and current trends in HIV infection among PWID and estimates the reach of harm reduction interventions in seven high drug use burden countries. Six of the countries—Thailand, Myanmar, Nepal, Indonesia, India, and Bangladesh—had significant epidemics of HIV among people who inject drugs. Although in five of the countries—Thailand, Indonesia, Bangladesh, Myanmar, and India—there is no significant decline in the prevalence of HIV epidemics for PWID, in Nepal, north-east India, and some cities in Myanmar there is some evidence of decline in risk behaviors and a concomitant decline in HIV prevalence. This is countered, however, by the rapid emergence of epidemics in new geographical pockets. Program data suggest that less than 12,000 of the estimated 800,000 (1.5 percent) people who inject drugs have access to opioid substitution therapy, and 20 to 25 percent were reached by needle-syringe programs at least once during the past 12 months.

Modeling carried out for the AIDS 2031 project suggests that AIDS resource requirements will increase rapidly over the next five to eight years and will continue to rise over the subsequent 15 years. Funding required for developing countries to address the pandemic could reach $35 billion annually by 2031—three times the current level. Even then, more than a million people will still be newly infected each year. Despite this bleak outlook, the authors contend that policy choices focusing on high-impact prevention and efficient treatment could cut costs by half. Major savings are possible if efforts are focused on high-impact prevention for most-at-risk populations—sex workers, men who have sex with men, and injecting drug users—who suffer from stigma and discrimination and from governments’ limited willingness to channel resources their way. The authors advocate broader structural changes, lower treatment costs, and low-cost, high-quality delivery approaches consisting of tightly supervised local clinics staffed with paraprofessionals and doctors. They also call for expanding HIV prevention tools to include a combination of new technologies, such as an AIDS vaccine or treatment leading to a cure, as well as outline six policy actions to expand financing for HIV in low- and middle-income countries.

In December, 2008, Senegal hosted the International Conference on AIDS and Sexually Transmitted Infections in Africa, a prestigious regional conference highlighting advancements in HIV prevention, treatment, and support in Africa. Directly following the conference, the Senegalese government arrested nine members of AIDES Senegal, a nongovernmental organization that works on HIV prevention and support for people living with HIV. The men were ultimately convicted as homosexuals and received a sentence of five years in prison. Only following significant international pressure, and after the men had spent almost three months in jail, were the convictions overturned on appeal. This article outlines discrimination and stigma, such as the above-mentioned example, faced by men who have sex with men (MSM) living with HIV. In many countries, MSM with HIV are not able to access their full rights, due either to repressive laws or discrimination, or, in some countries, death. Violations of rights are not reported for fear of reprisals, and if reported are not taken seriously. The author emphasizes that laws, perceptions, and practices need to change quickly to ensure that MSM with HIV are able to exercise their full rights as citizens, including the right to life, the right to form families, and the right to good health.

Access to reproductive health services for women with HIV is critical for ensuring that their reproductive needs are addressed and their reproductive rights protected. In addition, preventing unintended pregnancies in women with HIV is an essential component of any comprehensive prevention of mother-to-child transmission (PMTCT) program. According to the authors, thanks to the emergence of health systems strengthening as a priority of the global health initiative, there is now an opportunity to advance the linkages between sexual and reproductive health and HIV. Unfortunately, however, despite consensus that preventing unintended pregnancies in women with HIV is critical to achieving PMTCT goals, HIV programs are falling short in making these essential linkages. HIV funders and policymakers must overcome certain obstacles, including: 1) the narrow focus of current PMTCT programs on treating women with HIV who are already pregnant; 2) separate, parallel funding mechanisms for sexual and reproductive health and HIV programs; 3) political resistance from major HIV funders and policy-makers to include sexual and reproductive health as an important HIV program component; and 4) gaps in the evidence base regarding effective approaches for integrating sexual and reproductive health and HIV services.

Rapid Advice: Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants

World Health Organization

Based on the latest scientific evidence, on December 1, 2009, the World Health Organization (WHO) issued new recommendations on treatment, prevention, and infant feeding in the context of HIV. WHO now recommends earlier initiation of antiretroviral therapy for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission (PMTCT) of HIV. For the first time, WHO recommends the use of ARVs earlier in pregnancy (starting at 14 weeks), and promotes the use of ARVs while breastfeeding to prevent HIV transmission. WHO also recommends that breastfeeding continue until the infant is 12 months old, provided the HIV-positive mother or baby is taking ARVs during that period. National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care. According to WHO, the new PMTCT recommendations have the potential to reduce mother-to-child HIV transmission risk to 5 percent or lower. Combined with improved infant feeding practices, the recommendations can also help to improve child survival.

The President’s Emergency Plan for AIDS Relief (PEPFAR) country teams and PEPFAR partner countries are in the process of developing partnership framework agreements that will guide both PEPFAR and partner country HIV/AIDS objectives and programming over the next five years. Physicians for Human Rights (PHR) analyzed how the four agreements finalized as of mid-November, 2009, for Malawi, Swaziland, Lesotho, and Angola, and a later draft for Kenya, address three issues related to stigma and discrimination: legal and regulatory reform, stigma and discrimination in the health sector, and recognition of the need to address stigma and discrimination against people with disabilities. While the agreements vary in approach, PHR found that the initial partnership framework agreements inadequately incorporate PEPFAR’s goals of creating stigma-free HIV programs and reaching even the most marginalized populations. Most of the agreements fail to address the need for legal and policy reform with respect to securing the equal rights of women. Similarly, the majority of the agreements addressed the issues of stigma and discrimination within the health sector either inadequately or not at all. According to PHR, these failures run the risk that PEPFAR programs will respond insufficiently to such matters and miss an opportunity to catalyze legal and policy reform in partner countries.

The Uganda AIDS Commission (UAC), in collaboration with a team of medical and communication experts, is revamping its national HIV information campaign after HIV prevention messages were less successful than hoped. The term high-risk sex—previously defined as sex with an irregular partner—is to be redefined as sex with anyone whose HIV status is not known. As such, the term “most at-risk populations” will no longer refer to specific groups such as sex workers, fishing communities, and men who have sex with men, but to all members of the population engaging in risky sex. Campaigns aimed at ending cross-generational sex will be abandoned in favor of generic warnings about engaging in risky sex because of fears that young people may believe that sex within their own generation is risk-free. Officials have also said factors such as alcohol abuse, which predispose people to risky sexual behavior, must be tackled alongside HIV prevention. The new messages will attempt to bring the HIV response in line with the drivers of the epidemic. Several senior officials have called for the return of fear-driven campaigns, although detractors of this method say the key to success in prevention is education, not fear.

The HIV Prevention Update provides a representative sample of summaries and abstracts of recent articles on global HIV prevention issues from a variety of scientific, peer-reviewed journals. It also includes state-of-the-art program resources, such as tools, curricula, program reports, and unpublished research findings.

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